Course of mental symptoms in patients with stress-related exhaustion: does sex or age make a difference?

Increased plasma levels of neuro-related proteins in patients with stress-related exhaustion: A longitudinal study

Exhaustion disorder (ED) is a stress-related disorder characterized by physical and mental symptoms of exhaustion. Recent data suggest that pathophysiological processes in the central nervous system are involved in the biological mechanisms underlying ED. The aims of this study were to investigate if plasma levels of neuro-related proteins differ between patients with ED and healthy controls, and, if so, to investigate if these differences persist over time. Using the Olink Neuro Exploratory panel, we quantified the plasma levels of 92 neuro-related proteins in 163 ED patients at the time of diagnosis (baseline), 149 patients at long-term follow-up (7-12 years later, median follow-up time 9 years and 5 months), and 100 healthy controls. We found that the plasma levels of 40 proteins were significantly higher in the ED group at baseline compared with the control group. Out of these, the plasma levels of 36 proteins were significantly lower in the ED group at follow-up compared with the same group at baseline and the plasma levels of four proteins did not significantly differ between the groups. At follow-up, the plasma levels of two proteins were significantly lower in the ED group compared with the control group. These data support the hypothesis that pathophysiological processes in the central nervous system are involved in the biological mechanisms underlying ED.

Self-rated health and its bidirectional relationship with burnout, sleep quality and somatic symptoms in a general adult population

The aim of this study was to investigate how self-rated health (SRH) reflects ongoing ill-health and how SRH is associated with previous ill-health and/or predicts future ill-health such as burnout, disturbed sleep, and somatic symptoms. The study used two waves from the population-based Västerbotten Environmental and Health Study in which 2 336 adult persons participated by answering a questionnaire at two time points three years apart. Hierarchical and logistic regression analyses were conducted, thus treating all variables both continuously (degree) and categorically (case). The analyses were performed both cross-sectionally and longitudinally. The results showed bidirectionality between suboptimal SRH and burnout, disturbed sleep and somatic severity caseness. Moreover, degree of poor SRH was more likely to occur simultaneously to high degrees of burnout and somatic severity than to degree of poor sleep quality. Also, caseness of burnout, disturbed sleep and somatic severity increased the risk of simultaneous suboptimal SRH. Finally, the results showed that degree of burnout three years earlier, predicted degree of poor SRH, and that degree of poor SRH predicted degree of sleep three years later. In conclusion, in a population-based, normal adult sample there is a bidirectional relationship between suboptimal SRH and caseness of burnout, disturbed sleep quality and somatic symptoms, but not between degree of these symptoms. The results can have implications for health care meeting patients complaining about poor general health.

A network analysis of exhaustion disorder symptoms throughout treatment

BACKGROUND

Stress-induced Exhaustion Disorder (ED) is associated with work absenteeism and adverse health outcomes. Currently, little is known regarding how the symptoms of ED are interrelated and whether the patterns of symptoms influence treatment outcomes. To this end, the current study applied network analyses on ED patients participating in a multimodal intervention.

METHODS

The first aim of the study was to explore the internal relationships between exhaustion symptoms and identify symptoms that were more closely related than others. A second aim was to examine whether the baseline symptom network of non-responders to treatment was more closely connected than the baseline symptom networks of responders, by comparing the sum of all absolute partial correlations in the respective groups' symptom network. This comparison was made based on the hypothesis that a more closely connected symptom network before treatment could indicate poorer treatment outcomes. Network models were constructed based on self-rated ED symptoms in a large sample of patients (n = 915) participating in a 24-week multimodal treatment program with a 12-month follow-up.

RESULTS

The internal relations between self-rated exhaustion symptoms were stable over time despite markedly decreased symptom levels throughout participation in treatment. Symptoms of limited mental stamina and negative emotional reactions to demands were consistently found to be the most closely related to other ED symptoms. Meanwhile, sleep quality and irritability were weakly related to other exhaustion symptoms. The symptom network for the full sample became significantly more closely connected from baseline to the end of treatment and 12-month follow-up. The symptom network of non-responders to treatment was not found to be more closely connected than the symptom network of responders at baseline.

CONCLUSIONS

The results of the current study suggest symptoms of limited mental stamina and negative emotional reactions to demands are central ED symptoms throughout treatment, while symptoms of irritability and sleep quality seem to have a weak relation to other symptoms of ED. The implications of these findings are discussed in relation to the conceptualization, assessment, and treatment of ED.

TRIAL REGISTRATION

The clinical trial was registered on Clinicaltrials.gov 2017-12-02 (Identifier: NCT03360136).

"Recovery activities are needed every step of the way"-exploring the process of long-term recovery in people previously diagnosed with exhaustion disorder

BACKGROUND

Sick-leave rates are high due to stress-related illnesses, but little is still known about the process of recovery from these conditions. The aim of this study was to explore the experiences of the recovery process, 6 to 10 years after treatment in people previously diagnosed with exhaustion disorder (ED), focusing on facilitators and barriers for the process of recovery from ED, and recovery activities experienced as helpful during the recovery process.

METHOD

Thirty-eight participants (average age: 52 years, 32 females) previously diagnosed with ED were interviewed with semi-structured interviews 6-10 years after undergoing treatment. The interviews were analyzed with thematic analysis.

RESULTS

Three themes resulted from the analysis. The first theme, "A long and rocky road", summarizes the fluctuating path to feeling better and emphasizes barriers and facilitators that affected the process of recovery, with a focus on external life events and the participants' own behaviors. Facilitators were changing workplace, receiving support, a reduction in stressors, and changed behaviors. Barriers were a poor work environment, caregiver responsibilities, negative life events and lack of support. The second theme "Recovery activities are needed every step of the way" describes how both the need for recovery activities and the types of activities experienced as helpful changed during the recovery process, from low-effort recovery activities for long periods of time to shorter and more active recovery activities. Recovery activities were described as important for self-care but hard to prioritize in everyday life. The last theme, "Reorienting to a new place", captures the struggle to cope with the remaining impact of ED, and how internal facilitators in terms of understanding and acceptance were important to reorient and adjust to a new way of functioning.

CONCLUSIONS

Recovering from ED is a long and ongoing process where recovery activities are needed every step of the way. Our results highlight the importance of supporting personal recovery and long-term behavioral change, addressing individual stressors that may perpetuate the condition, and adjusting recovery activities according to where the person is in the recovery process.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT0073772 . Registered on March 8, 2017. This study was pre-registered on Open Science Framework (osf.io).

Differences in psychiatric comorbidity patterns in patients diagnosed with chronic stress-induced exhaustion disorder and depression - A cohort study in the total population of Region Stockholm

The high prevalence of stress-related disorders and depression underscores the urgent need to unravel their impact on individual well-being. This study aim to investigate common psychiatric and stress-related diagnoses, along with postviral fatigue, in individuals with prior stress-induced exhaustion disorder (SED) and prior depression compared to those without prior SED or depression, and to study whether the psychiatric comorbidity patterns differ. The study includes individuals in Region Stockholm who, in 2011, did not have a diagnosis of SED or depression. ICD-10 diagnosis of SED, depression, or both, recorded in 2012-2013, were compared to individuals without prior SED or depression in a cohort (n = 1,362,886), aged 18 to 65. Odds ratios (OR) with 99 % confidence intervals, adjusted for age and neighborhood socioeconomic status, were calculated for psychiatric disorders and post-viral fatigue in 2014-2022. Patients with prior SED showed associations primarily with stress related diagnoses, including acute stress reaction, reaction to severe stress, as well as post-COVID-19 and post-viral fatigue syndrome. These ORs were all larger for SED than depression. Depression was primarily associated with post-traumatic stress disorder (PTSD), alcohol related and substance use disorders, schizophrenia, schizotypal disorders, delusional disorders, manic episode, bipolar affective disorder, persistent mood disorder, neurotic disorder, borderline personality disorder, autistic disorder, Asperger's syndrome, attention -deficit hyperactivity disorder, attention-deficit disorders ADHD/ADD), and suicide attempt. These ORs were all higher for depression, although autistic disorders, ADHD/ADD and PTSD were also highly associated with prior SED (OR > 3.5). The divergent psychiatric comorbidity patterns suggest different underlying mechanisms and clinical prognosis.

Psychologists' involvement in and experiences of treating patients with stress-related exhaustion in primary care

BACKGROUND

Primary health care is the setting for most patients with stress-related mental health problems. Good care processes are important for patients with stress-related mental health problems and the complex needs of these patients has become a challenge for primary care settings which is traditionally designed to manage acute episodes of one illness. The care process of these patients is thus interesting to investigate. The aim of this study was to explore psychologists´ involvement and experiences regarding the organisation of the care process and treatment of patients seeking care for stress-related exhaustion.

METHOD

Fifteen psychologists (14 women and 1 man, age range 27-72 years)c from fifteen different primary health care centres in the western part of Sweden, located in both rural and urban areas were included. Qualitative content analysis of individual semi-structured interviews was conducted.

RESULTS

The analysis resulted in eight subcategories within the two main categories studied illuminating psychologists' involvement and experiences regarding the organisation of the care process and challenges regarding treatment of patients seeking care for stress-related exhaustion.

CONCLUSION

The care process of patients with stress-related exhaustion is perceived to be ineffective and not congruent with the needs of the patients. A lack of holistic overview of the care process, a lack of collaboration and poor utilization of the health care professionals' competence leads to an unstructured process forcing the patients to be the carriers and coordinators of their own care.

Is the road to burnout paved with perfectionism? The prevalence of obsessive-compulsive personality disorder in a clinical longitudinal sample of female patients with stress-related exhaustion

OBJECTIVES

Few studies have investigated the relationship between stress-related mental health problems and obsessive-compulsive personality disorder (OCPD). Similarly, little research has focused on the moderating effect of OCPD on recovery in clinical patients with stress-related mental health problems. The general aim of this study was to investigate the prevalence of OCPD and the associations between OCPD and level of burnout, anxiety, and depression symptoms, during a 7-years follow-up in a clinical longitudinal sample of female patients with stress-related exhaustion.

METHOD

The included patients (n = 84) were referred to a specialist outpatient clinic for patients with stress-related exhaustion between 2006 and 2011. Data was collected at the initial examination and during a 7-year treatment follow-up.

RESULTS

OCPD was the most common personality disorder in the present clinical sample, with 40% of patients fulfilling the criteria. There was a significant association between OCPD and the degree of burnout symptoms as well as the degree of depression, both at baseline and during the 7-year follow-up. No significant association between OCPD and levels of anxiety was observed.

CONCLUSION

The results support the hypothesis that there might be an association between OCPD and stress-related exhaustion, including preservation of symptoms over time. OCPD and its related traits, such as perfectionism, may be important factors to consider when constructing effective treatment and rehabilitation plans for these patients.

Effectiveness of a person-centred eHealth intervention in reducing symptoms of burnout in patients with common mental disorders - secondary outcome analysis of a randomized controlled trial

BACKGROUND

The number of people with common mental disorders (CMDs), especially stress-related disorders, has increased in several countries, including Sweden, during the past decade. Patients seeking care for long-term stress report severe symptoms. Although person-centred care (PCC) has shown several benefits, studies evaluating the effects of a PCC eHealth intervention on patients with CMDs are scarce.

OBJECTIVE

The aim of this study was to compare levels of self-reported symptoms of burnout between a control group receiving treatment as usual (TAU) and an intervention group receiving TAU with the addition of a person-centred eHealth intervention, in patients on sick leave for CMDs.

METHODS

This study reports analysis of a secondary outcome measure from a randomized controlled trial. Patients (n = 209) on sick leave for CMDs were recruited from nine primary health care centres and allocated to either a control group (n = 107) or an intervention group (n = 102). The intervention consisted of phone support and an interactive digital platform built on PCC principles. Self-reported symptoms of burnout were assessed using the Shirom-Melamed Burnout Questionnaire (SMBQ) at baseline and at 3 and 6 months.

RESULTS

Our findings showed changes in SMBQ scores over time in both the control and the intervention group. There was no significant difference in SMBQ scores between the groups; however, a difference in change over time between the groups was observed. The SMBQ scores decreased significantly more in the intervention group than in the controls between 0 and 3 months and between 0 and 6 months. No differences in change between the two groups were seen between the 3- and 6-month follow-ups.

CONCLUSION

This person-centred eHealth intervention for patients on sick leave for CMDs showed a slight initial effect in reducing symptoms of burnout. Taking into account that both groups reported comparable SMBQ scores throughout the study period, the overall effect may be considered limited.

TRIAL REGISTRATION

The trial was registered in ClinicalTrials.gov (Identifier NCT03404583). Date of registration: 19/01/2018. https://clinicaltrials.gov/ct2/show/NCT03404583 .

Somatic symptoms in burnout in a general adult population

OBJECTIVE

Burnout results in individual suffering and high societal costs, and is associated with somatic symptoms, anxiety and depression, calling for prevention by early identification. The objectives were to (i) determine prevalence of specific somatic symptoms in burnout, (ii) identify the symptoms, referred to as somatic symptoms of burnout (SS-B), that are particularly associated with burnout, (iii) determine their extent of association with burnout, and (iv) determine how well a certain number of SS-B differentiates participants with and without burnout in a general Swedish adult population.

METHODS

Cross-sectional, population-based data were used from 687 participants high on burnout, and 2544 referents based on the Shirom-Melamed Burnout Questionnaire. The Patient Health Questionnaire 15-item Somatic Symptom Severity Scale was used to assess common somatization symptoms, and the Hospital Anxiety and Depression Scale to assess anxiety and depression.

RESULTS

Feeling tired/having low energy, back pain, joint/limb pain, trouble sleeping, headaches, stomach pain, nausea/gas/indigestion, and constipation/loose bowels/diarrhea were most prevalent in burnout (57.2-95.0%). These symptoms, except for joint/limb pain, and dizziness, were also identified as the SS-B, with odds ratios of 2.34-12.74 and 1.95-9.11 when adjusted for background variables, and for anxiety and depression, respectively. Corresponding odds ratios for each additional number of SS-B were 1.69 and 1.52, respectively. The highest balanced accuracy (71.6%) for predicting burnout was found for ≥4 SS-B.

CONCLUSION

Fatigue, pain and gastrointestinal symptoms are particularly common in burnout. Further studies may show whether clinicians should consider screening for burnout when patients present with SS-B without pathophysiological explanations.

Organizational and psychosocial environmental work factors associated with self-rated exhaustion disorder among municipal employees in rural northern Sweden

BACKGROUND

Research indicates that good organizational and psychosocial environments are vital to well-functioning workplaces and employee health. Working in the municipal sector and in the rural context may contribute to more health problems, poorer organizational and psychosocial work environments, and higher sick-leave rates.

OBJECTIVE

The aim of this study was to explore organizational and psychosocial environmental work factors among municipal employees with or without self-rated exhaustion disorder (s-ED) in rural northern Sweden.

METHODS

The Modern Work Life Questionnaire and the Self-Rated Exhaustion Disorder Scale were used among 1093 municipal employees.

RESULTS

The results showed that there were significant differences between the s-ED and the non-s-ED group in all but one of the organizational and psychosocial environmental work factors. Various demands, i.e. quantitative, emotional, intellectual, and IT demands were some factors associated with the s-ED group. Social support, resources, and time for work and reflection were some factors associated with the non-s-ED group. Both the s-ED and the non-s-ED groups assessed significantly higher emotional demands and less resources compared to national reference values.

CONCLUSION

Findings from this study are relevant to a better understanding what organizational and psychosocial work environmental work factor the employer need to pay extra attention to. Addressing risk and protective factors in the work environment could tribute to promote occupational well-being, preventing exhaustion disorder and long-term sick leave among municipal employees in rural northern Sweden.

Do objective and subjective measures of cognitive impairment predict occupational status in patients with work-related stress? A clinical follow-up study

OBJECTIVE

Cognitive impairment is a common complaint in prolonged work-related stress and may contribute to work disability. The objective was to evaluate the longitudinal impacts of objectively and subjectively measured cognitive impairment on occupational status and to evaluate the measurement's predictive properties regarding occupational prognosis in patients with work-related stress.

METHODS

Patients with work-related stress (n = 82) were assessed with Danish versions of the Screen for Cognitive Impairment in Psychiatry (SCIP-D) and the Cognitive Failure Questionnaire (CFQ), as screeners of objective and subjective cognitive impairments, respectively. Patients were contacted via telephone at 6-month follow-up providing data on occupational status (employment vs. non-employment). Impacts of cognitive impairment on occupational status were evaluated using logistic regression analyses adjusting for other explanatory covariates (sociodemographic factors, comorbidities etc.). The predictive performance of SCIP-D and CFQ were evaluated using non-adjusted logistic regression analysis and receiver-operating-characteristics curves.

RESULTS

There was a strong association between objective cognitive impairment measured with SCIP-D and non-employment when adjusting for other explanatory factors (OR adjusted 3.25, 95% CI 1.09-9.69). The association was attenuated but remained robust in the non-adjusted analysis (OR non-adjusted 1.74, 95% CI 1.08-2.81). Yet, a cut-score of SCIP-D performed inadequate as a sole predictor of occupational status. Subjective cognitive impairment was unrelated to subsequent occupational status.

CONCLUSIONS

Objective-but not subjective-cognitive impairment was associated with subsequent non-employment. Our results suggest a predictive potential in objective measurements of cognitive impairment with significant implications for clinical assessment of patients with work-related stress.

Biomarkers of brain injury in patients with stress-related exhaustion: A longitudinal study

INTRODUCTION

Exhaustion Disorder (ED) is a stress-induced disorder, characterized by extreme fatigue, cognitive impairments, and intolerance to stress. These symptoms can be long-lasting, suggesting that the long-term stress may have initiated pathophysiological processes in the brains of patients with ED. The aims of the study were I) to investigate if plasma levels of neurofilament light (NfL), glial fibrillary acidic protein (GFAP), and phosphorylated tau (p-tau181) differ between patients with ED and healthy controls, and II) to investigate if these differences persist over time.

METHOD

Plasma NfL, GFAP and p-tau181 were quantified in 150 patients with ED at the time of diagnosis (baseline), 149 patients at long-term follow-up (7-12 years later, median follow-up time 9 years and 5 months), and 100 healthy controls.

RESULTS

Plasma levels of NfL and GFAP were significantly higher in the ED group at baseline compared with controls (mean difference of NfL 0.167, 95 % CI 0.055-0.279; mean difference of GFAP 0.132, 95 % CI 0.008-0.257), while p-tau181 did not differ between the groups. Plasma levels of NfL were significantly lower in the ED group at follow-up than in the same group at baseline (mean difference -0.115, 95 % CI -0.186-(-0.045)), while plasma levels of GFAP did not differ between the groups, and plasma levels of p-tau181 were significantly higher in the ED group at follow-up than in the same group at baseline (mean difference 0.083, 95 % CI 0.016-0.151). At follow-up, there were no significant differences between the ED group and the control group for any of the proteins.

CONCLUSION

Plasma levels of NfL and GFAP were increased in patients with ED during the first months of the disease, indicative of axonal and glial pathophysiological processes, but had normalized at long-term follow-up.

Having allies—Experiences of support in people with stress-related exhaustion: A qualitative study

Background

The number of people seeking care for symptoms of exhaustion and stress is a major concern in several countries. The condition is a challenging and life-changing experience, and a deeper understanding of support to help people on sick leave due to stress-related exhaustion in their early stages is needed to facilitate recovery.

Objective

The aim was to explore experiences of support in people with stress-related exhaustion being on sick-leave less than six months.

Method

A qualitative interview study was conducted with 12 participants (7 women and 5 men; aged 25–46 years) who were on sick leave that had not exceeded six months due to stress-related exhaustion. The participants were recruited from public healthcare centres in the western part of Sweden, and the intention was to reach them early in their ongoing sick leave period. The interviews were performed face-to-face and analysed using a phenomenological hermeneutical approach.

Results

The findings show that people affected by stress-related exhaustion struggle to maintain their dignity and define support in terms of allies who acknowledge their personhood and provide them helpful guidance. Participants expressed their needs to be taken seriously by professionals, family, and friends willing to engage in their situation. Lack of empathy and professional knowledge in the clinical encounter induced additional stress.

Conclusions

This study indicates that people affected by stress-related exhaustion need allies from their surrounding networks in their struggle to maintain their dignity. Our findings highlight that it is essential to acknowledge them as persons and establish an alliance to provide appropriate support based on each person’s specific situation, needs and resources. This approach can be facilitated in a partnership, as emphasized in person-centred care (PCC). PCC emphasizes the co-creation of care in partnership between the patient (often with relatives) and health care professionals which may imply a more collaborative view of health care in which patients are engaged as active partners in planning their care.

Healthcare utilisation among patients with stress-induced exhaustion disorder treated with a multimodal rehabilitation programme - a longitudinal observational study

BACKGROUND

Stress-induced exhaustion disorder is a major challenge in Swedish working life. Despite its increase in prevalence, there is still limited knowledge about the effectiveness of different rehabilitation methods. In this study, we aim to describe the healthcare utilisation for patients with stress-induced exhaustion disorder before, during and after a multi-modal rehabilitation (MMR) programme, as well as the health-related quality of life, work ability, sick leave level and psychological measures, and their possible relations.

METHODS

In this longitudinal observational study, 53 patients who were part of an MMR programme at the Stress Rehabilitation Clinic participated with survey data, and among them 43 also contributed with healthcare data. Data were collected from one year before start of MMR to one year after the end of it. The patients also answered a questionnaire at the start of, end of and at a one-year follow-up of the MMR, which included questions about health-related quality of life, work ability, clinical burnout, sick leave level, anxiety and depression.

RESULTS

There was a statistically significant increase in healthcare consumption during MMR, if including visits to the Stress Rehabilitation Clinic, while it decreased if excluding such visits, when comparing with before and after MMR. During the follow-up period there was a non-statistically significant (p=0.11), but still rather large difference (15.4 compared with 12.0 visits per patient), in healthcare consumption in comparison with the period before MMR, when excluding follow-up visits at the Stress Rehabilitation Clinic. Health-related quality of life was rated as poor before MMR (mean 0.59). There was a statistically significant improvement, but values were still below normal at the end of follow-up (mean 0.70). In addition, the level of sick leave, the work ability and signs of clinical burnout improved statistically significantly after MMR, but were not fully normalised at the end of follow-up. Individual healthcare consumption was related to residual health problems.

CONCLUSIONS

Patients with stress-induced exhaustion disorder have not reduced their healthcare consumption notably after MMR, and residual health problems remain for some patients. More studies are needed for a deeper understanding of the individual effectiveness of MMR, and also of its cost-effectiveness.

Exhaustion disorder: scoping review of research on a recently introduced stress-related diagnosis

BACKGROUND

Symptoms related to chronic stress are prevalent and entail high societal costs, yet there is a lack of international consensus regarding diagnostics and treatment. A new stress-related diagnosis, exhaustion disorder, was introduced into the Swedish version of ICD-10 in 2005. Since then, use of the diagnosis has increased rapidly.

AIMS

To create the first comprehensive synthesis of research on exhaustion disorder to report on the current state of knowledge. Preregistration: Open Science Framework (http://www.w3.org/1999/xlink">osf.io), doi 10.17605/OSF.IO/VFDKW.

METHOD

A PRISMA-guided scoping review of all empirical studies of exhaustion disorder was conducted. Searches were run in the MEDLINE, PsycInfo and Web of Science databases. Data were systematically charted and thematically categorised based on primary area of investigation.

RESULTS

Eighty-nine included studies were sorted into six themes relating to lived experience of exhaustion disorder (n = 9), symptom presentation and course (n = 13), cognitive functioning (n = 10), biological measures (n = 24), symptom measurement scales (n = 4) and treatment (n = 29). Several studies indicated that individuals with exhaustion disorder experience a range of psychiatric and somatic symptoms beyond fatigue, but robust findings within most thematic categories were scarce. The limited number of studies, lack of replication of findings and methodological limitations (e.g. small samples and scarcity of specified primary outcomes) preclude firm conclusions about the diagnostic construct.

CONCLUSIONS

More research is needed to build a solid knowledge base for exhaustion disorder. International collaboration regarding the conceptualisation of chronic stress and fatigue is warranted to accelerate the growth of evidence.

The role of self-reported stressors in recovery from Exhaustion Disorder: a longitudinal study

BACKGROUND

Exhaustion disorder (ED) is a stress-induced disorder characterized by physical and mental symptoms of exhaustion that can be long-lasting. Although stress exposure is essential for the development of ED, little is known regarding the role of stressors in the maintenance of ED. The aim of the study was to investigate the role of work-related stressors, private-related stressors, and adverse childhood experiences in long-term recovery from ED.

METHODS

A mixed methods design was used. The design was sequential, and data analysis was performed in two parts, where the first part consisted of qualitative analysis of patient records, and the second part consisted of statistical analysis of the data retrieved from the qualitative coding. Patient records from 150 patients with ED was analysed regarding work-related stressors, private-related stressors, and adverse childhood experiences. For each patient, two patient records were analysed, one from the time of diagnosis (baseline) and one from the follow-up clinical assessment, 7-12 years after diagnosis (follow-up). Out of the 150 patients, 51 individuals still fulfilled the diagnostic criteria for ED at follow-up (ED group) and 99 individuals no longer fulfilled the diagnostic criteria and were thus considered recovered (EDrec). Percentages in each group (ED and EDrec) reporting each stressor at baseline and follow-up were calculated as well as the differences in percentage points between the groups along with the 95% confidence intervals for the differences.

RESULTS

At baseline, significantly more EDrec patients reported quantitative demands (73% EDrec, 53% ED) and managerial responsibilities (14% EDrec, 2% ED). Private-related stressors did not differ at baseline. At follow-up, significantly more ED patients reported managerial responsibilities (8 ED, 0% EDrec) and caregiver stress (child) (24% ED, 6% EDrec) and significantly more EDrec patients reported caregiver stress (parent) (6% EDrec, 0% ED). There were no differences regarding adverse childhood experiences.

CONCLUSIONS

The main conclusion is that neither adverse childhood experiences nor any of the stressors at baseline are associated with long-term ED. Ongoing stressors related to having responsibility for other people, such as managerial responsibilities or caring for a child with a chronic disease or psychiatric disorder, may be associated with long-term exhaustion.

Alcohol Use among Swedish Patients with Stress-Induced Exhaustion Disorder, and Its Relation to Anxiety, Depression, and Health-Related Quality of Life

Harmful drinking may be a cause and an effect of psychological distress, and compromises the effects of treatment for psychiatric conditions. There is a paucity of studies investigating patterns of alcohol consumption among patients with stress-induced exhaustion disorder (SED). The aims of this investigation were (1) to assess the prevalence of self-rated hazardous drinking in a sample of 808 Swedish patients with SED (mean age 43 ± 9 years, 84% women), and (2) to investigate differences in sociodemographic variables, psychological symptoms, health-related quality of life, and sleep variables between patients with different drinking patterns The design was cross-sectional and data were collected with questionnaires at pre-treatment. Twelve percent of female and 13% of male patients reported Alcohol Use Disorder Identification Test (AUDIT) scores indicating hazardous drinking. Female patients with hazardous drinking reported higher levels of anxiety and depression and lower mental wellbeing, than other women. Female patients reporting no drinking reported poorer physical function and more pain, than other women. No differences were seen between male patients with different drinking patterns. Although patients with SED report a lower frequency of harmful drinking than other psychiatric samples, alcohol consumption needs to be addressed in the assessment and treatment of this condition.

"Who I Am Now, Is More Me." An Interview Study of Patients' Reflections 10 Years After Exhaustion Disorder

Aim: To achieve a deeper understanding of the patient's perception regarding individual aspects related to the development of exhaustion, hindering and supporting factors in the recovery process, and potential remaining consequences, 7-12 years after receiving an exhaustion disorder diagnosis. Participants and Methods: Twenty patients previously diagnosed with and treated for exhaustion disorder were interviewed 7-12 years after onset of the disease. The semi-structured interviews were transcribed verbatim and analyzed with inductive content analysis. Results: Three main themes with patterns of shared meaning resulted from the analysis: "it's about who I am," "becoming a more authentic me," and "the struggle never ends." The interviewees described rehabilitation from exhaustion disorder as the start of an important personal development toward a truer and more authentic self-image. They perceived this as an ongoing long-lasting process where learned behavior and thought patterns related to overcommitment and overcompliance needed to be re-evaluated. The results also convey long-term consequences such as cognitive difficulties and reduces energy, uncertainty about one's own health, and the need to prioritize among one's relationships. Conclusion: Patients with exhaustion disorder are still struggling with dysfunctional strategies and functional impairments such as cognitive problems which limit their lives, 10 years after receiving their exhaustion disorder diagnosis. While informants describe some positive consequences of ED, the results also emphasize the importance of acknowledging that the patients are embedded in systems of relationships, in working life as well as in family life. This needs to be considered, together with other aspects, when working toward prevention of stress-related mental health problems.

Impaired cognitive functioning in stress-induced exhaustion disorder: a new tablet-based assessment

BACKGROUND

The adverse health effects of stress induced exhaustion disorder (SED) cause increasing concern in Western societies. This disorder is characterized by severe fatigue, decreased tolerance to further stress, and attention and memory lapses. Despite subjective complaints, individual cognitive deficits are not always detected in a clinical setting, which calls for the validation of more sensitive instruments.

AIM

The objective of this study was to investigate if a short, tablet-based serial naming task, MapCog Spectra (MCS) could be used as a marker for cognitive problems in SED.

PARTICIPANTS

The study comprised of 39 subjects (35 females, four males) with SED. Their mean age was 46,8 years (SD 10.1; range 30-60 yrs.). All participants were healthcare professionals, with a college or university degree, doctors, registered nurses, and psychologists.

METHODS

The MCS was used to assess the number of aberrant pauses during serial naming of coloured geometrical shapes. The Coding, Matrix Reasoning, Digit Span, Symbol Search of the WAIS-IV, and RUFF 2&7 tests, were administered together with a short interview.

RESULTS

Mean values were within normal reference limits for all tests, except for the MCS, which showed a significantly higher number of aberrant pauses (p < 0,001) in the SED group, compared to normal reference values. Although subjects performed within normal limits on the RUFF 2&7, a significant difference between individuals was found in the performance strategy of the participants.

CONCLUSION

Here we report that subjects with SED have performance deficits on the MCS, in terms of aberrant pause times, despite average performance on WAIS-IV tests measuring inductive reasoning, processing speed, working memory, and attention. We also demonstrate that subjects use different strategies to overcome their problems. These findings add to the growing evidence of cognitive deficits in SED and that the MCS might aid neuropsychologists in disentangling cognitive markers, important to substantiate the subjective complaints of affected individuals.

"I'm So Tired": Fatigue as a Persistent Physical Symptom among Working People Experiencing Exhaustion Disorder

Fatigue is widespread in the population, particularly among working people. Exhaustion disorder (ED), a clinical manifestation of burnout, is common, but, after treatment, about one-third still experience fatigue and other physical symptoms. We propose that in some instances, fatigue as a persistent physical symptom (PPS) might be a more appropriate formulation of ED patients' fatigue problems, and we suggest that ED patients who meet fatigue PPS criteria will differ from other ED patients in terms of psychological distress, non-fatigue PPSs and functional impairment. Questionnaires were sent to 10,956 members of a trade union of which 2479 (22.6%) responded. Of 1090 participants who met criteria for ED, 106 (9.7%) met criteria for fatigue as a PPS. Participants who met fatigue PPS criteria scored on average higher on measures of depression, anxiety and functional impairment and were more likely to have clinically significant scores. Moreover, they had 27 times higher odds of meeting other PPS subtypes and reported more non-fatigue PPS subtypes, suggesting a more complex health problem. Specific evidence-based interventions are available for both ED and PPSs, and therefore, it is crucial to accurately formulate the fatigue problem reported by patients to provide appropriate treatment.

Nature-Based Rehabilitation for Patients with Long-Standing Stress-Related Mental Disorders: A Qualitative Evidence Synthesis of Patients' Experiences

Stress-related mental disorders contribute to work disabilities globally and are a common cause for sick leave. Nature-based rehabilitation (NBR) is a multi-disciplinary approach offered to this patient group on a limited scale. Qualitative studies provide insight into patients’ experiences of NBR, and there is a need to synthesize and assess the certainty of evidence for patient-experienced benefits. The aim was to identify, appraise, and synthesize studies reporting experiences and perceived benefits of participation in multidisciplinary, group-based NBR of adult patients with long-standing stress-related mental disorders. PubMed, Embase, CINAHL, AMED, APA PsycInfo, and the Cochrane Library were searched from inception to December 2020. Reference lists of relevant publications were searched. After title and abstract screening, full-text articles were retrieved and assessed for inclusion. The methodological quality of the included studies was assessed, and certainty of evidence was appraised according to CERQual. The search yielded 362 unique records; 19 full-text publications were assessed for eligibility, and 5 studies were included in the synthesis. The studies were considered relevant regarding context, population, and intervention, and quality was generally assessed as moderate to high. Extracted texts were inductively coded and organized into 16 descriptive themes and 4 broad, analytical themes: Instilling calm and joy; Needs being met; Gaining new insights; and Personal growth. Experiences and perceived benefits of participating in NBR and spending time in a nature environment were described as positive for recovery. Nine of the descriptive themes were based on explicit results from at least four of the five studies. Confidence in the evidence of the qualitative findings ranged from moderate to low. Moderate-to-low certainty evidence from the included studies suggests that patients with long-standing stress-related mental disorders experience positive health effects from participating in NBR.

Self-reported changes in work situation - a cross-sectional study of patients 7 years after treatment for stress-related exhaustion

BACKGROUND

Exhaustion disorder (ED) is a common cause of sick leave in Sweden, and patients often have long-lasting symptoms and reduced work capacity. The aim of this study was to explore whether patients with ED had made any changes in their work situation from the period of treatment and up to 7 years later.

METHODS

In this cross-sectional study, patients diagnosed with ED at a specialist outpatient clinic were followed up after 7 years (n = 217). They received questionnaires at baseline covering sex, age, marital status, level of education, and symptoms of burnout, depression, and anxiety measured with the Shirom-Melamed Burnout Questionnaire and the Hospital Anxiety and Depression Scale. After 7 years, they were sent a follow-up questionnaire asking about their work situation and work-related stressors both before they fell sick and at the 7-year follow-up. There were three questions on work situation (change of workplace, change of work tasks, and change of working hours), and 155 patients responded to all three.

RESULTS

After 7 years, the majority of the patients (63%; n = 98/155) reported that they had made some kind of change at work. Women were more likely than men to report decreased working hours (p = 0.001), and work-related stressors such as conflicts at work, reorganization, deficient leadership, and general discontent with the work situation were significantly more common at baseline in the group who had made changes at work. Patients who made no changes at work experienced more work-related stress due to quantitative demands in the 7-year follow-up.

CONCLUSION

The majority of the patients with ED made some kind of change in their work situation, and gender differences were found for changes of work tasks and working hours. Work-related stressors might be decisive for making changes at work.

Is obsessive-compulsive personality disorder related to stress-related exhaustion?

OBJECTIVE

Recovery from stress-related diagnoses can, in some cases, be long-lasting, and several different factors could be related to such a lengthy recovery. One plausible aspect is obsessive-compulsive personality disorder (OCPD), which has previously been seen to be related to stress-related mental health. Thus, the aim of this study was to investigate whether recovery from exhaustion disorder (ED) is associated with OCPD.

METHODS

This study includes data from 147 patients (78% women, mean age 52.4 ± 9.8 years) who have been treated for ED. Clinical assessment was performed 7-10 years after first seeking care identifying patients with residual exhaustion. Symptoms of OCPD were concomitantly measured and several aspects of work- and private-related stress exposure.

RESULTS

The main result of this study is that patients with residual clinical ED report OCPD to a greater extent, compared with patients who no longer fulfill the clinical criteria for ED, 7-10 years after seeking care. Patients with OCPD that have not recovered report "excessive devotion to work" to a higher degree than patients with OCPD that have recovered.

CONCLUSION

The results indicate that factors related to OCPD may be of clinical importance for the patient's recovery from ED. However, prospective studies should be conducted and studies elucidating whether symptoms of exhaustion among patients with OCPD can be affected by therapeutic interventions.

Enhanced Capacity to Act: Managers' Perspectives When Participating in a Dialogue-Based Workplace Intervention for Employee Return to Work

Purpose To explore if and how a dialogue-based workplace intervention with a convergence dialogue meeting can support a return to work process from the managers' perspective. Methods Individual interviews were conducted with 16 managers (10 women and 6 men) who had an employee on sick leave because of stress-induced exhaustion disorder. The manager and employee participated in a dialogue-based workplace intervention with a convergence dialogue meeting that was guided by a healthcare rehabilitation coordinator. The intervention aimed to facilitate dialogue and find concrete solutions to enable return to work. The interviews were analyzed by the Grounded Theory method. Results A theoretical model was developed with the core category enhancing managerial capacity to act in a complex return to work process, where the managers strengthened their agential capacity in three levels (categories). These levels were building competence, making adjustments, and sharing responsibility with the employee. The managers also learned to navigate in multiple systems and by balancing demands, control and support for the employee and themselves. An added value was that the managers began to take preventive measures with other employees. When sick leave was caused only by personal or social issues (not work), workplace actions or interventions were difficult to find. Conclusions From the managers' perspective, dialogue-based workplace interventions with a convergence dialogue meeting and support from a rehabilitation coordinator can strengthen managerial competence and capacity to act in a complex return to work process.

Self-reported cognitive impairment and daily life functioning 7-12 years after seeking care for stress-related exhaustion

The overall aim of this study was to investigate self-reported cognitive difficulties, daily life activities, and health/sleep factors in former patients with exhaustion disorder (ED) who still fulfill the clinical criteria for exhaustion 7-12 years after seeking care. The Sahlgrenska Self-reported Cognitive Impairment Questionnaire (SASCI-Q) was used to measure cognitive difficulties, daily life activities, and health/sleep factors. Three groups were compared: previous patients still judged to be clinically exhausted seven years or more after seeking care (n = 51); previous patients considered clinically recovered (n = 98); and healthy controls (n = 50). Patients who still fulfilled the diagnostic criteria for ED reported widespread problems related to cognition, fatigue, and daily life functioning compared to the clinically recovered group. Furthermore, despite no longer fulfilling the clinical criteria, the recovered patients still reported more problems related to cognitive functioning and fatigue compared to healthy controls. Thus, this group appeared intermediary between the non-recovered group and healthy controls regarding self-reported cognitive functioning. To conclude, ED may have considerable negative long-term effects, and it is possible that some of these residual symptoms, particularly the cognitive problems and persistent fatigue, are permanent in some patients. Preventive measures should be the primary focus for all stakeholders, since the consequences of stress-related mental health problems seem to be extensive and long-lasting.

Supporting parents of children with chronic conditions: A randomized controlled trial of web-based and self-help ACT interventions

OBJECTIVE

Many parents of children with chronic conditions and developmental disabilities experience high rates of burnout and psychological distress. The aim of the current study was to examine the effects of two differently delivered interventions based on acceptance and commitment therapy (ACT) on symptoms of burnout, depression, quality of life, psychological flexibility, and mindfulness skills.

METHOD

A total of 110 parents of children aged 0.8 to 17 years with chronic conditions and developmental disabilities participated in a randomized controlled trial lasting 13 weeks with two intervention groups: (1) an iACT intervention, including three psychologist-led video conferencing sessions, and (2) a self-help ACT, which received self-help material: an ACT-based booklet with the possibility of using ACT-based online exercises.

RESULTS

For the main outcome measure burnout, a similar decrease was found in both groups. The supported iACT intervention produced significantly larger improvements in depressive symptoms (d = 0.49), psychological flexibility (d = 0.64), and mindfulness (d = 0.55) compared to the self-help ACT intervention. For health-related quality of life, only the dimension of role limitations caused by emotional problems showed a significant difference in favor of the supported iACT (d = 0.58).

CONCLUSIONS

The results suggest that the iACT intervention including three video conferencing sessions with a psychologist produced broader improvements in parents' psychological well-being than the self-help ACT. Overall, Internet-delivered interventions and video conferencing technology may offer a feasible alternative to psychological support and self-care for parents of children with chronic conditions. Further research is needed to investigate the long-term effects of the current delivery models.

Association Between Erythrocyte Levels of n-3 Polyunsaturated Fatty Acids and Risk of Frailty in Community-Dwelling Older Adults: The Korean Frailty and Aging Cohort Study

BACKGROUND

Inflammation is a major risk factor for frailty, but n-3 polyunsaturated fatty acids (PUFA) has been suggested as an anti-inflammatory agent. The present study aimed to investigate the hypothesis that the higher erythrocyte levels of long-chain n-3 PUFA were associated with lower odds of frailty and frailty criterion.

METHODS

Cross-sectional analysis from the Korean Frailty and Aging Cohort Study, a total of 1,435 people aged 70-84 years were included. Sex- and age-stratified community residents, drawn in urban and rural regions nationwide, were eligible for participation in the study. All participants were categorized as frail and nonfrail according to the Cardiovascular Health Study index.

RESULTS

The likelihood of frailty was inversely associated with the erythrocyte levels of eicosapentaenoic acid (EPA; odds ratio [OR] per unit 0.33; 95% confidence interval [CI] 0.14-0.77; p for trend = .002) and docosahexaenoic acid (DHA; OR per unit 0.42; 95% CI 0.20-0.87; p for trend = .018). Among each frailty criterion, the likelihood of slow walking speed was associated with erythrocyte levels of EPA and DHA, and the likelihood of exhaustion was inversely associated with the erythrocyte levels of DHA.

CONCLUSIONS

The present study showed that the frailty and frailty criterion were significantly associated with lower erythrocyte levels of long-chain n-3 PUFA, suggesting that lower n-3 PUFA could be a marker for the risk of frailty.

Leakage of astrocyte-derived extracellular vesicles in stress-induced exhaustion disorder: a cross-sectional study

Patients with stress-induced exhaustion disorder (SED) demonstrate cognitive dysfunction similar to patients with minor traumatic brain injury (TBI). We have previously detected elevated concentrations of astrocyte-derived extracellular vesicles (EVs) in patients with TBI. As such, we hypothesized that astrocyte-derived EVs could be higher in patients with SED than in patients with major depressive disorder (MDD) and healthy controls. Patients with SED (n = 31), MDD (n = 31), and healthy matched controls (n = 61) were included. Astrocyte-derived EVs (previously known as microparticles) were measured in plasma with flow cytometry and labeled against glial fibrillary acidic protein (GFAP) and aquaporin 4 (AQP4). In addition, platelet EVs and their CD40 ligand expression were measured. Patients with SED had significantly higher concentrations of AQP4 and GFAP-positive EVs and EVs co-expressing AQP4/GFAP than patients with MDD and healthy controls. Patients with MDD had significantly higher concentrations of GFAP-positive EVs and EVs co-expressing AQP4/GFAP than healthy controls. Platelet EVs did not differ between groups. CD40 ligand expression was significantly higher in patients with SED and MDD than in controls. In conclusion, the present study suggests that patients with SED, and to some extent, patients with MDD, have increased leakage of astrocyte-derived EVs through the blood–brain barrier.

The hypothalamo-pituitary-adrenal axis and the autonomic nervous system in burnout

Burnout constitutes a serious health concern in the modern working environment. It is a stress-related condition that has developed as a result of a prolonged psychosocial stress exposure causing a persistent mismatch between demands and resources. The main symptom is emotional exhaustion, but physical fatigue, diminished professional efficacy, cynicism, and cognitive impairments are also associated with this condition. Burnout has been used both as a psychologic term in occupational settings and as a clinical diagnosis in patient populations, and there is currently no universally accepted definition and diagnostic criteria of burnout. It has been hypothesized that the two main stress response systems, the autonomic nervous system (ANS) and the hypothalamus-pituitary-adrenal axis (HPA axis), are involved in the pathogenesis of burnout. A common hypothesis is that in the early stages of chronic stress, the HPA axis and sympathetic ANS activity tend to be higher, while it will decrease with a longer duration of chronic stress to ultimately reach a state of hypoactivity in clinical burnout. The current research in this field shows many contradictory results. Thus there is no compelling evidence of either ANS or HPA dysfunction in burnout. However, there is partial support for the hypothesis of HPA and sympathetic hyperactivity in early stages, and HPA hyporeactivity and low vagal activity in more severe burnout cases, but high-quality studies investigating the causal links are still lacking.

Exhaustion disorder and altered brain activity in frontal cortex detected with fNIRS

Patients with stress-related Exhaustion Disorder (ED) have problems with memory and executive function. These problems have been associated with deviant activity in prefrontal cortex (PFC). We investigated cognitive performance and functional activity in the PFC during prolonged mental activity in patients with ED (n = 20, 16 women) with a mean duration since diagnosis of 46 ± 23 months in comparison to healthy individuals (n = 20, 12 women). A block of six neuropsychological tests was performed in a sequence that was repeated once. The brain imaging technique, functional near infrared spectroscopy (fNIRS) was used for all tests. There were no differences between the groups in terms of changes over time, i.e. difference between first and second test block. In the Stroop-Simon test, the controls showedhigher functional activity in the frontal cortex. In the left ventrolateral PFC, we observed an increased activity in controls in the incongruent compared to the congruent trials, whereas no changes were detected in the ED patient group. During processing speed tasks, only ED patients showed higher functional activity in right dorsolateral PFC. The ED patients reported lower subjective energy level and they also performed less well on a mental control task compared to healthy individuals. In conclusion, ED patients showed altered functional activity compared to controls, indicating that ED patients process information differently in the prefrontal cortex, but the functional activity did not change during the 2½ hr procedure, as revealed by the test-retest design. Lay summary In this paper we show that patient with exhaustion disorder have a reduced functional activity in the prefrontal cortex. This functional activity was not affected by 2.5 hours mental activity.

Self-rated exhaustion disorder and associated health-related factors among municipal employees in rural areas of northern Sweden

OBJECTIVE

The aims of this study among municipal employees in rural areas of northern Sweden were to assess the prevalence of self-rated exhaustion disorder (s-ED), describe plausible between-group differences in self-reported health-related factors among employees with or without s-ED, and identify health-related factors associated with s-ED.

METHODS

In a cross-sectional study, data were collected from 1093 municipal employees (76.1% women) in two rural areas using an instrument measuring s-ED and health variables drawn from the Modern Worklife Questionnaire (MWQ), the Perceived Stress Scale (PSS), and the National Board of Health and Welfare's questions about physical activity. Comparisons were made between an s-ED and a non-s-ED group. Health-related factors associated with s-ED were identified through a logistic regression.

RESULTS

Self-rated exhaustion disorder was reported by 21.5% of the participants. Health-related factors associated with s-ED were cognitive problems, sleep problems, depressive symptoms, high stress, poor self-rated health, and stomach problems. There was no statistically significant difference in the prevalence of participants who met the criteria of physical activity among s-ED and non-s-ED group.

CONCLUSION

Findings from this study suggest that s-ED is more common among municipal employees in rural areas than in other working populations in Sweden. Several health-related factors were associated with s-ED. Regular use of a self-rated instrument in evaluating the organizational and social work environment can identify people at risk of developing exhaustion disorder and requiring long-term sick leave.

Restoring confidence in return to work: A qualitative study of the experiences of persons with exhaustion disorder after a dialogue-based workplace intervention

Background

Stress-induced exhaustion disorder (SED) is a primary cause for sickness absence among persons with mental health disorders in Sweden. Interventions involving the workplace, and supporting communication between the employee and the supervisor, are proposed to facilitate return to work (RTW). The aim of this study was to explore experiences of persons with SED who participated in a dialogue-based workplace intervention with a convergence dialogue meeting performed by a rehabilitation coordinator.

Methods

A qualitative design based on group interviews with 15 persons with SED who participated in a 24-week multimodal rehabilitation program was used. The interviews were analyzed with the methodology of grounded theory.

Results

The analysis resulted in a theoretical model where the core category, restoring confidence on common ground, represented a health promoting process that included three phases: emotional entrance, supportive guidance, and empowering change. The health promoting process was represented in participant experiences of personal progress and safety in RTW.

Conclusions

The intervention built on a health-promoting pedagogy, supported by continuous guidance from a rehabilitation coordinator and structured convergence dialogue meetings that enhanced common communication and collaboration with the supervisor and others involved in the RTW process. The intervention balanced relationships, transferred knowledge, and changed attitudes about SED among supervisors and colleagues in the workplace. The inclusion of a rehabilitation coordinator in the intervention was beneficial by enhancing RTW and bridging the gaps between healthcare, the workplace, and other organizational structures. In addition, the intervention contributed to a positive re-orientation towards successful RTW instead of an endpoint of employment. In a prolonged process, a dialogue-based workplace intervention with convergence dialogue meetings and a rehabilitation coordinator may support sustainable RTW for persons with SED.

Mental fatigue in stress-related exhaustion disorder: Structural brain correlates, clinical characteristics and relations with cognitive functioning

•

Structural correlates of mental fatigue investigated in stress-related exhaustion.

•

Patients were divided into high and low-moderate mental fatigue group.

•

Patients with high mental fatigue had smaller caudate and putamen volumes.

•

No significant differences in cortical thickness between the groups.

•

Mental fatigue mediated the relationship between caudate volume and working memory.

Emerging evidence suggests that mental fatigue is a central component of the cognitive and clinical characteristics of stress-related exhaustion disorder (ED). Yet, the underlying mechanisms of mental fatigue in this patient group are poorly understood. The aim of this study was to investigate cortical and subcortical structural neural correlates of mental fatigue in patients with ED, and to explore the association between mental fatigue and cognitive functioning. Fifty-five patients with clinical ED diagnosis underwent magnetic resonance imaging. Mental fatigue was assessed using the Concentration subscale from the Checklist Individual Strength. Patients with high levels of mental fatigue (n = 30) had smaller caudate and putamen volumes compared to patients with low-moderate levels of mental fatigue (n = 25). No statistically significant differences in cortical thickness were observed between the groups. Mediation analysis showed that mental fatigue mediated the relationship between caudate volume and working memory; specifically, smaller caudate volume was associated with higher level of mental fatigue and mental fatigue was positively associated with working memory performance. Our findings demonstrate that the structural integrity of the striatum is of relevance for the subjective perception of mental fatigue in ED, while also highlighting the complex relationship between mental fatigue, cognitive performance and its neural underpinnings.

Long-term follow-up of residual symptoms in patients treated for stress-related exhaustion

Background

Many patients with stress-related exhaustion seem to struggle with long-term recovery. The primary aim of this study was to explore residual symptoms and perceived recovery in patients previously treated for stress-related exhaustion, 7 years after seeking care.

Methods

A total of 217 former patients (74% women) previously treated for exhaustion disorder were asked to participate in follow-ups 2, 3, 5, and 7 years post treatment. Symptoms of depression, and anxiety were measured with questionnaires. Remaining symptoms of extreme fatigue, sleep disturbances, problems with concentration, problems with memory and reduced stress tolerance, were rated with single item questions. A subgroup of patients (n = 163) participated in a clinical assessment to confirm residual stress-related exhaustion not caused by other diseases.

Results

Almost half of the patients previously treated for stress-related exhaustion perceive fatigue 7 years after initially seeking care, and as many as 73% reported decreased stress tolerance. The clinical assessment confirmed that a third of the patients were clinically judged as still suffering from stress-related exhaustion. Male and female patients showed similar patterns regarding residual symptoms.

Conclusions

One third of patients with exhaustion disorder are clinically judged to have exhaustion, 7 years after seeking care. Further studies are needed to elucidate the reason for such a long-term recovery and ultimately to identify methods for prevention.

Hopeful struggling for health: Experiences of participating in computerized cognitive training and aerobic training for persons with stress-related exhaustion disorder

It is important to understand how people with exhaustion disorder (ED) perceive interventions aiming to facilitate cognitive functioning. Therefore, the overall aim of this study was to explore experiences from persons with ED after participating in a 12-week intervention of either computerized cognitive training or aerobic training. Both interventions were performed in addition to a multimodal rehabilitation programme. Thirteen participants, 11 women and 2 men, were interviewed about pros and cons with participating in the training. The interviews were analysed with Qualitative Content Analysis. The analyses resulted in the theme hopeful struggling for health and the categories support, motivation and sensations. It was hard work recovering from ED. Support from others who are in the same situation, family members, and technology and routines for the training were strongly emphasized as beneficial for recovery. Timing, i.e., matching activities to the rehabilitation programme, getting feedback and perceiving joy in the training were important for motivation. Participants in both interventions experienced positive sensations with improved memory performance, everyday life functioning and increased faith in the prospect of recovery. However, it is important to consider various aspects of support and motivation in both computerized cognitive training and aerobic training to enable participants to pursue their participation.

Longitudinal associations between cardiorespiratory fitness and stress-related exhaustion, depression, anxiety and sleep disturbances

Background

In the last few years, so-called “common mental disorders”, including adjustment disorder and stress-related exhaustion, have outrivalled musculoskeletal disorders as being the leading cause of long-term sick leave in Sweden. Cardiorespiratory fitness level defined as “the maximal amount of physiological work that an individual can do as measured by oxygen consumption” has in many studies shown to reduce the risk of several life-style related diseases and moreover to improve mood, well-being and physical performance. The aim of the present study was to investigate, longitudinal associations between cardiorespiratory fitness and self-reported physical activity levels and the severity of symptoms connected to stress-related exhaustion, depression, anxiety, and sleep disturbances among women clinically diagnosed with stress-related exhaustion disorder (ED).

Methods

The study was that of a longitudinal cohort study consisting of women (n = 88) diagnosed with stress-related ED in a specialist clinic in Gothenburg, Sweden. Cardiorespiratory fitness was measured with the Åstrand indirect test of maximal oxygen uptake (VO₂max) and subjective measures of physical activity levels were rated on 4-graded physical activity scale. To measure and follow symptoms of ED over time the SMBQ-questionnaire (Shirom Melamed Burnout Questionnaire) was used. The Hospital Anxiety and Depression Scale (HADS) was used to measure depression and anxiety. A proxy variable for capturing overall disturbed sleep used to measure sleep. Longitudinal associations for continuous outcome variables and the dichotomous variable sleep were analysed using mixed- effects regression models with random intercepts. Regression coefficients along with the 95% confidence interval (CI) are presented as measures of association. Both exposures and the outcome were measured simultaneously over six waves (T1–T6).

Results

The results showed statistically significant associations between level of fitness and reduced symptoms of stress-related exhaustion over time. Best improvements over time were seen in patients having a medium cardiorespiratory fitness level. No associations could be found between cardiorespiratory fitness level over time and anxiety, depression or sleep disturbances.

Conclusion

Having medium cardiorespiratory fitness was positivity associated with a more sustained reduction in symptoms of ED overtime compared to those having low or high cardiorespiratory fitness levels. The clinical implication following this result is that an individual recommendation based on a medium level of physical activity in line with the recommendations from ACSM (American College of Sports Medicine) is preferable compared to recommendations including more vigorous physical activity in order to restore and sustainably reduce symptoms of exhaustion disorder over time.

Newly educated care managers' experiences of providing care for persons with stress-related mental disorders in the clinical primary care context

Objective

Our aim was to explore how the care managers put the complex care manager task into practice and how they perceived their task, which was to facilitate effective, person-centred treatment for stress-related disorder concordant with evidence-based guidelines in primary care.

Design

This was a qualitative study using examination reports from the course for care managers. Systematic text condensation according to Malterud was used for the analysis.

Setting

Primary health care centres

Subject

Twenty-eight newly educated care managers in primary health care participated in the study. The median age was 50 (31–68) years. Twenty-seven were women and one was a man. Twenty-one were employed as nurses and seven as counsellors.

Results

The informants perceived the role as care manager as meaningful but at times complicated. To participate in teams and to work closely with the general practitioner was experienced as important. The co-ordinating function was emphasised as especially important, as well as the increased continuity in care. The dual role as care manager and counsellor was sometimes experienced as problematic.

Conclusion

The informants took advantage of the knowledge they had attained during the course. They perceived themselves as being a bridge between patients and other professionals. The result of having dual roles at the primary health care centre unexpectedly revealed difficulties for some professionals. The nurses seemed more familiar with the new way of working.

Effects of cognitive behavioural therapy and return-to-work intervention for patients on sick leave due to stress-related disorders: Results from a randomized trial

The aim of this study was to evaluate specific effects for patients with adjustment or exhaustion disorder, the Stress subgroup (n = 152), regarding symptom severity and sick leave after CBT, a return-to-work intervention (RTW-I), and a combination of them (COMBO), using data from a randomized trial. In the original study, primary care patients on sick leave (N = 211) were randomized to CBT (n = 64), RTW-I (n = 67), or COMBO (n = 80). Blinded Clinician Severity Rating (CSR) of symptoms and sick leave registry data were primary outcomes. Subgroup analyses showed that for the Stress subgroup, CBT led to greater reduction of symptoms than RTW-I posttreatment, but COMBO did not differ from CBT or RTW-I. Regarding sick leave, there was no difference between treatments in the Stress subgroup. An exploratory analysis of the treatment effects in a subgroup of patients with depression, anxiety or insomnia indicates that RTW-I reduced sick leave faster than CBT. We conclude that CBT may be promising as an effective treatment of stress and exhaustion disorder.

Growth factors and neurotrophins in patients with stress-related exhaustion disorder

Growth factors, such as vascular endothelial growth factor (VEGF) and epidermal growth factor (EGF), and neurotrophic factors, including brain-derived neurotophic factor (BDNF), have attracted attention in studies of the biological effects of long-term stress exposure due to their neuroprotective roles. This study investigated whether circulating levels of EGF, VEGF and BDNF were altered in individuals with stress-related exhaustion disorder. Forty patients diagnosed with exhaustion disorder and 40 healthy subjects (50% women) provided fasting blood samples for analysis of EGF, VEGF, and BDNF in plasma. We found significantly lower levels of EGF, VEGF, and BDNF in patients with ED compared to healthy controls. This pattern was seen in both male and female patients. Given the important roles of BDNF and VEGF for brain plasticity and neurogenesis, decreased levels after long-term stress exposure could indicate increased risk of neuronal damage and cognitive impairments in this patient group.

Psychometric Properties and Convergent Validity of the Shirom-Melamed Burnout Measure in Two German-Speaking Samples of Adult Workers and Police Officers

Burnout is considered an occupation-related psychological syndrome consisting of emotional, physical, and cognitive exhaustion. To assess dimensions of burnout, the Shirom-Melamed Burnout Measure (SMBM) is widely used, but its validity and reliability have rarely been examined in adult samples. The aim of this study is to examine the psychometric properties of the German version of the SMBM in two independent samples of adults. In total, 311 adult workers and 201 police officers completed the SMBM, and questionnaires related to perceived stress and mental well-being. Descriptive statistics, internal consistency, convergent validity, and factorial validity were assessed for both samples, separately for male and female participants. The German SMBM had adequate psychometric properties and sufficient convergent validity. In confirmatory factor analyses, we found a good fit for both the first- and second-order model. Furthermore, measurement invariance across gender was observed in both samples. Although the SMBM is a popular instrument among burnout researchers, this study demonstrates for the first time that the SMBM can be considered a valid and reliable tool to assess burnout symptoms in both male and female adults and across different professional groups. Furthermore, with its 14 items, the SMBM is a succinct and economic self-assessment tool for symptoms of burnout.

Concurrent and lagged effects of psychosocial job stressors on symptoms of burnout

Purpose

Burnout is a mental condition described as being a result of long-term stressors commonly related to psychosocial factors at work. The aim of the present study was to investigate longitudinal relationships between job demands, decision authority, effort and reward, and symptoms of burnout, as well as the joint effects of job demands and decision authority, and of effort and reward.

Methods

The data came from a four-wave longitudinal cohort study of Swedish health care workers. Longitudinal associations were analysed using mixed effects regression models with random intercept.

Results

The concurrent analysis showed that demand and decision authority, as well as effort and reward, were associated with symptoms of burnout over time. Evidence of the lagged effects of workplace factors on burnout symptoms was limited to reward. No clear effect modification was found.

Conclusion

An increase in unfavourable working conditions implied increasing scores on the burnout measure over time. The concurrent effects of job demands, decision authority, effort and reward on symptoms of burnout were seen. The evidence of lagged effects was limited to the low-reward condition. Regularly monitoring these work environment conditions at workplaces can help identify risk situations for burnout and thus be useful in the prevention of work-related mental illness. Lastly, a new approach to defining the risk groups was proposed, which is consistent across different populations and time points.

Electronic supplementary material

The online version of this article (10.1007/s00420-019-01437-0) contains supplementary material, which is available to authorized users.

Comparison of exhaustion symptoms in patients with stress-related and other psychiatric and somatic diagnoses

BACKGROUND

Several rating scales assessing stress-related symptoms of exhaustion have emerged in recent years. However, more knowledge is needed about the performance of these rating scales in patients with stress-related disorders as well as in other patient groups. With the recently developed Karolinska Exhaustion Disorder Scale (KEDS), we compared symptoms of exhaustion in different patient groups that were sorted according to diagnosis.

METHODS

Patients were sampled consecutively from departments of occupational medicine (DOM) at three Danish hospitals. The total study group comprised 698 care-seeking patients (487 women). Patients with stress-related diagnoses (n = 217; the International Classification of Diseases [ICD]-10 code F43: reaction to severe stress and adjustment disorder) were compared to a diverse group of patients with a range of somatic diagnoses (n = 338) and to patients with other psychiatric diagnoses (n = 143), including subgroups with major depression disorder (n = 34; F32 and F33) and problems related to employment and unemployment (n = 99; Z56). The data were analysed using linear mixed models with the SPSS statistical program.

RESULTS

The mean KEDS sum score in patients with stress-related diagnoses (29.3; SD = 8.0) was significantly higher than in patients with other psychiatric diagnoses (25.9; SD = 9.5) and in patients with somatic diagnoses (17.6; SD = 10.8). The subgroup with a major depression disorder had high mean KEDS sum scores (31.4, SD = 8.1), similar to patients with stress-related diagnoses, while the mean KEDS sum score in patients with problems related to employment and unemployment (Z56) was 23.5 (SD = 9.0). Young and old patients scored similarly on KEDS, but in patients with somatic diagnoses, female patients scored significantly higher than male patients.

CONCLUSION

The symptoms of exhaustion measured with KEDS were higher in patients with stress-related diagnoses and major depression disorder than in patients with somatic diagnoses. The intermediate level of the symptoms of exhaustion that were associated with problems related to employment and unemployment, (Z56) compared to the lower level of the symptoms with somatic diagnoses, suggests that KEDS might be useful in detecting mild, prodromal states of exhaustion. This needs further investigation.

MECHANISMS IN ENDOCRINOLOGY: Endocrine and immunological aspects of burnout: a narrative review

Burnout has several different definitions, and attempts have been made to discriminate between burnout as a psychological construct and burnout as a clinical entity. A large body of research has focused on elucidating the biological link between stress exposure and burnout and/or finding a clinically usable biomarker for burnout. The objective of this narrative review is to summarize the main endocrine and immune findings in relation to burnout. The literature has primarily focused on dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis. However, albeit the large body of studies, it cannot be concluded that clear effects are seen on HPA axis function in people with burnout. The HPA axis and anabolic acute reactivity to stress might be affected in clinical burnout. Plausible, effects of chronic stress might rather be seen when measuring responses to acute stress rather than resting state hormonal levels. Studies on other hormones, including thyroid hormones, prolactin and growth hormone in burnout subjects are inconclusive. It is important to note that this field is faced with many methodological challenges, one being the diurnal and pulsatile nature of many of the hormones of interest, including cortisol, which is not always considered. Another challenge is the heterogeneity regarding definitions and measurements of stress and burnout. Existing studies on burnout and immune function are heterogeneous regarding the results and no firm conclusion can be made if clinically relevant immune changes are present in burnout subjects. An overall conclusion is that existing research cannot confirm any homogenous reliable endocrinological or immunological changes related to burnout.

Plasma metabolomic patterns in patients with exhaustion disorder

Exhaustion disorder (ED) is a stress-related disorder that often implies a great burden on the individual patient as well as on society. Previous studies have shown that ED is associated with metabolic deviations, such as lowered fasting glucose. Several mechanisms have been discussed as a plausible explanation of the lack of energy described by these patients. Metabolic processes and reduced ability to mobilize energy have been suggested as important factors. This study investigated metabolomics in 20 patients diagnosed with ED and compared them with 21 healthy controls. Plasma metabolic profiles were examined in both fasting and nonfasting (postprandial) conditions. Blood plasma samples were analyzed for metabolite content using gas chromatography mass spectrometry. A total of 62 different metabolites were simultaneously detected in each of the samples. Multivariate models indicated systematic differences between patients with ED and healthy controls in both their fasting and nonfasting plasma metabolite levels. Lysine and octadecenoic acid were more abundant and glutamine, glycine, serine and gluconic acid were less abundant in the patients across both conditions. In the present study, we comprehensively and simultaneously screen for changes in a large number of metabolites. Our results show a difference in systemic metabolites between patients with exhaustion disorder and healthy controls both in the fasting and in the postprandial states. Here, we present new potential biomarkers mirroring exhaustion disorder metabolism. Lay summary Exhaustion disorder (ED) patients suffer from stress-related symptoms including a reduced energy level. This study investigates the body's metabolism in patients with ED, both fasting and after a meal. New potential markers that may help future investigations on ED were identified.

Symptoms that may be stress-related and lead to exhaustion disorder: a retrospective medical chart review in Swedish primary care

BACKGROUND

Mental illness, and particularly stress-related disorders such as exhaustion disorder, is continuously increasing in today's society. It is important to identify patients who consult for potentially stress-related symptoms early, before the stress condition develops into an exhaustion disorder. The purpose of the study was to investigate the frequency of different presenting complaints for which patients had consulted in the two years preceding receipt of their exhaustion disorder diagnosis, and to explore potential associations between stress-related presenting complaints and demographic factors, as well as comorbidity and other potentially stress-inducing factors.

METHODS

This was a retrospective medical chart review of presenting complaints of adult patients with exhaustion disorder two years preceding receipt of diagnosis at a primary healthcare centre in western Sweden.

RESULTS

Exhaustion disorder was diagnosed in 126 patients at the healthcare centre during the study period. Charts were available for 115 patients (76% women, mean age 47 years). Charts were reviewed with regard to presenting complaints, demographic data and comorbidity. Average number of general practitioner visits during the two years preceding the diagnosis was 5.2 (SD 3.7). The two most common complaints were infection and anxiety/depression, presented by 49% and 46%, respectively. Other stress-related complaints seen to in more than 30% of the patients were stress, other pain, fatigue, gastrointestinal symptoms, and sleep disturbances. Back pain and fatigue were more frequent in patients over 40 years. A majority of the patients also had mental (53%) or somatic (61%) comorbidity. Comorbidity was more frequent in older patients. No significant gender differences were found.

CONCLUSIONS

Patients with exhaustion disorder appear to consult their general practitioner numerous times with stress-related complaints in the years preceding their diagnosis. The findings indicate which presenting complaints general practitioners may need to be more attentive to so that patients at risk of developing exhaustion disorder can be identified earlier and get the support they need. Addressing stress factors earlier in the course of illness and preventing the development of exhaustion disorder may contribute to a reduced burden for both individual patients and for society, with a reduction in sick leave and societal costs for mental illness.

Involving the employer to enhance return to work among patients with stress-related mental disorders - study protocol of a cluster randomized controlled trial in Swedish primary health care

BACKGROUND

Work-related stress has become a major challenge for social security and health care systems, employers and employees across Europe. In Sweden, sickness absence particularly due to stress-related disorders has increased excessively in recent years, and the issue of how to improve sustainable return to work in affected employees is high up on the political agenda. The literature on interventions for return to work in patients with common mental disorders is still inconclusive. This randomized controlled trial (RCT) aims to contribute with knowledge about how physicians and rehabilitation coordinators in primary health care can involve the employer in the rehabilitation of patients with stress-related disorders. The objective is to evaluate whether the early involvement of the patient's employer can reduce the time for return to work compared to treatment as usual. A process study will complete the RCT with information about what prerequisites primary health caregivers need to succeed with this endeavor.

METHODS

Twenty-two primary care centers were randomized to either intervention or control group. At the intervention centers, physicians and rehabilitation coordinators underwent training, providing them with both knowledge and practical tools to involve the employer in rehabilitation. At the patient level, employed patients with an ICD-10 F43 diagnosis were eligible for participation (n=132). Difference in proportion of patients on full- or part-time sick leave at three, six and 12 months after inclusion will be investigated. Register data, logbooks and interviews with coordinators and physicians at both intervention and control centers will be used for process evaluation.

DISCUSSION

Although the issue of how to tackle work-related stress can be recognized all across Europe, Sweden face an urgent need to curb the disproportional increase of stress-related disorders in the sick-leave statistics. Since physicians are limited by time constraints, the rehabilitation coordinator may be a helpful resource to take this contact. The current study will contribute to knowledge about how this collaboration can be organized to facilitate employer involvement and reduce time to return to work among patients suffering from work related stress.

TRIAL REGISTRATION

Registered on 1 November 2016, ClinicalTrials.gov, NCT03022760 .

Relevance of Rodent Models of Depression in Clinical Practice: Can We Overcome the Obstacles in Translational Neuropsychiatry?

The diagnosis of a mental disorder generally depends on clinical observations and phenomenological symptoms reported by the patient. The definition of a given diagnosis is criteria based and relies on the ability to accurately interpret subjective symptoms and complex behavior. This type of diagnosis comprises a challenge to translate to reliable animal models, and these translational uncertainties hamper the development of new treatments. In this review, we will discuss how depressive-like behavior can be induced in rodents, and the relationship between these models and depression in humans. Specifically, we suggest similarities between triggers of depressive-like behavior in animal models and human conditions known to increase the risk of depression, for example exhaustion and bullying. Although we acknowledge the potential problems in comparing animal findings to human conditions, such comparisons are useful for understanding the complexity of depression, and we highlight the need to develop clinical diagnoses and animal models in parallel to overcome translational uncertainties.

Rehabilitation for improved cognition in patients with stress-related exhaustion disorder: RECO - a randomized clinical trial

Stress-related exhaustion has been associated with selective and enduring cognitive impairments. However, little is known about how to address cognitive deficits in stress rehabilitation and how this influences stress recovery over time. The aim of this open-label, parallel randomized controlled trial (ClinicalTrials.gov: NCT03073772) was to investigate the long-term effects of 12 weeks cognitive or aerobic training on cognitive function, psychological health, and work ability for patients diagnosed with exhaustion disorder (ED). One-hundred-and-thirty-two patients (111 women) participating in multimodal stress rehabilitation were randomized to receive additional cognitive training (n = 44), additional aerobic training (n = 47), or no additional training (n = 41). Treatment effects were assessed before, immediately after and one-year post intervention. The primary outcome was global cognitive function. Secondary outcomes included domain-specific cognition, self-reported burnout, depression, anxiety, fatigue and work ability, aerobic capacity, and sick-leave levels. Intention-to-treat analysis revealed a small but lasting improvement in global cognitive functioning for the cognitive training group, paralleled by a large improvement on a trained updating task. The aerobic training group showed improvements in aerobic capacity and episodic memory immediately after training, but no long-term benefits. General improvements in psychological health and work ability were observed, with no difference between interventional groups. Our findings suggest that cognitive training may be a viable method to address cognitive impairments for patients with ED, whereas the effects of aerobic exercise on cognition may be more limited when performed during a restricted time period. The implications for clinical practice in supporting patients with ED to adhere to treatment are discussed.

Effect of traditional yoga, mindfulness-based cognitive therapy, and cognitive behavioral therapy, on health related quality of life: a randomized controlled trial on patients on sick leave because of burnout

BACKGROUND

To explore if health related quality of life(HRQoL) increased after traditional yoga(TY), mindfulness based cognitive therapy(MBCT), or cognitive behavioral therapy(CBT), in patients on sick leave because of burnout.

METHODS

Randomized controlled trial, blinded, in ninety-four primary health care patients, block randomized to TY, MBCT or CBT (active control) between September 2007 and November 2009. Patients were living in the Stockholm metropolitan area, Sweden, were aged 18-65 years and were on 50%-100% sick leave. A group treatment for 20 weeks, three hours per week, with homework four hours per week. HRQoL was measured by the SWED-QUAL questionnaire, comprising 67 items grouped into 13 subscales, each with a separate index, and scores from 0 (worse) to 100 (best). SWED-QUAL covers aspects of physical and emotional well-being, cognitive function, sleep, general health and social and sexual functioning. Statistics: Wilcoxon's rank sum and Wilcoxon's sign rank tests, Bonett-Price for medians and confidence intervals, and Cohen's D.

RESULTS

Twenty-six patients in the TY (21 women), and 27 patients in both the MBCT (24 women) and in the CBT (25 women), were analyzed. Ten subscales in TY and seven subscales in MBCT and CBT showed improvements, p < 0.05, in several of the main domains affected in burnout, e.g. emotional well-being, physical well-being, cognitive function and sleep. The median improvement ranged from 0 to 27 points in TY, from 4 to 25 points in CBT and from 0 to 25 points in MBCT. The effect size was mainly medium or large. Comparison of treatments showed no statistical differences, but better effect (small) of both TY and MBCT compared to CBT. When comparing the effect of TY and MBCT, both showed a better effect (small) in two subscales each.

CONCLUSIONS

A 20 week group treatment with TY, CBT or MBCT had equal effects on HRQoL, and particularly on main domains affected in burnout. This indicates that TY, MBCT and CBT can be used as both treatment and prevention, to improve HRQoL in patients on sick leave because of burnout, reducing the risk of future morbidity.

TRIAL REGISTRATION

July 22, 2012, retrospectively registered. ClinicalTrails.gov NCT01168661 .

FUNDING

Stockholm County Council, grant 2003-5.